Volume 7-1, Spring 1998

Patellar Tendon ACL Reconstruction and Rehabilitation Practices and Opinions (Autograft versus Allograft): Orthopaedic Sports Medicine Fellowship Program Survey-- John Nyland, EdD, PT, ATC; David N. M. Caborn, MD; Darren L. Johnson, MD; John Moore, MS, ATC; Keith Slone, MS

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We wanted to determine the bonepatellar tendon-bone (BPTB) anterior cruciate ligament (ACL) reconstruction practices of accredited orthopaedic sports medicine fellowship programs and their opinions about whether differences should exist in rehabilitation protocol, bracing, and timing of release to cutting/agility sports between autogeneic and allogeneic grafts. Our survey showed most programs did 51 to 100 BPTB ACL reconstructions during the 12 months before survey completion. Standard rehabilitation protocols were used without differences based on BPTB graft type or fixation concerns. Programs were equally divided regarding whether BPTB graft type should be a timing of release to cutting/agility sports factor. Programs were almost equally divided regarding routinely prescribed derotation braces. More programs used autograft rather than allograft BPTB tissue for ACL reconstruction, without rehabilitation protocol differences based on graft type or fixation concerns. Conflicting results regarding protocol and timing of release to cutting/agility sports indicate that several factors may contribute to the clinical decision-making process. Equivocal results regarding derotation brace prescription raises concerns regarding their necessity.

Translaminar Lumbar Epidural Endoscopy: Technique and Clinical Results--Daniel Julio DeAntoni, MD; Maria Laura Claro, MD; Gary G. Poehling, MD; Steven S. Hughes, MD

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To provide baseline outcome data for a new lumbar microinvasive diskectomy done with standard arthroscopic instrumentation, we retrospectively reviewed the cases of 190 patients. All patients were assessed by a modified MacNab outcome classification with a minimum of a 2-year follow-up. All complications of this procedure were reported as well. No previous outcome data are available for this procedure, since it has been done primarily at one center, by the same surgeon, using his previously reported techniques. Results were good or excellent in 175 patients and fair or poor in 15. Complications were not severe and were easily remedied. This success rate is comparable to rates reported for other minimally invasive operations on the lumbar spine. This new technique of minimally invasive lumbar spine surgery provides minimal morbidity and a long-term outcome comparable to that of other standard procedures. The added benefits of using standard arthroscopic instrumentation are discussed.

Malunion/Nonunion of Radius and Ulna Shaft Fractures--W. Andrew Eglseder, Jr., MD

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Radius and ulna shaft malunions and nonunions are uncommon occurrences in this age of open reduction and internal fixation (ORIF). Malunions can be thought to occur in radius and ulna shaft fractures managed without operative intervention or internal fixation. Nonunions can be thought of as failure of union, for various reasons, after surgical intervention. However, both malunions and nonunions can occur in conservatively treated radius and ulna fractures. In a 1949 study1 of 41 radius and ulna fractures, 29% had satisfactory results and 71% had unsatisfactory results. Five patients went on to nonunion, a 12% incidence. A later review2 of 41 distal third radial shaft fractures (Galeazzi or Piedmont variants) showed that 38 were treated with closed reduction and casting, and had a 92% failure rate. A number of these cases subsequently went on to surgical intervention. This paper will define anatomic and biomechanic correlations of malunions and nonunions of radius and ulna shaft fractures and provide an overview of treatment options for malunions and nonunions of these fractures.

Glenoid Fracture: Conservative Treatment Versus Surgical Treatment--Mordechai Kligman, MD; Moshe Roffman, MD

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Glenoid fossa fractures are rare. The indication for conservative or surgical treatment is controversial, especially because of limited reports in the literature. Many authors prefer conservative treatment for most types of glenoid fractures to the alternate surgical treatment, but long-term follow-up is rarely reported. We report on four patients with displaced, intra-articular glenoid fossa, who were treated either surgically or conservatively. After an average 7-year followup, clinical and radiographic results were satisfactory in all patients. Based on the literature and our limited experience, we recommend that conservative treatment be considered as a good option for displaced intra-articular glenoid fossa fracture.

Biomechanical Analysis of Hindfoot Fixation Using an Intramedullary Rod--Samuel S. Fleming, MD; Thomas J. Moore, MD; William C. Hutton, DSc

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To measure the stiffness of the hindfoot when fixed with an intramedullary rod placed in a retrograde manner, two biomechanical experiments were carried out on five matched pairs of cadaveric below knee specimens. Experiment 1: In the right leg of each pair, an intramedullary rod was placed in a retrograde fashion through the calcaneus, talus, and into the tibial intramedullary canal. Biomechanical testing was done to determine hindfoot stiffness, with and without distal and proximal transverse interlocking screws. The uninstrumented left leg of each pair was tested as a control. Experiment 2: A series of similar biomechanical experiments were done on the same specimens to determine the effect on hindfoot stiffness of an intramedullary rod with one distal screw as compared with a method of tibiotalocalcaneal fixation using three cross-cannulated screws. The results show that an intramedullary rod placed in a retrograde manner stiffens the hindfoot and the placement of interlocking screws enhances that effect (Experiment 1). The intramedullary rod with one distal screw inserted provides more stiffness to the hindfoot than does three cross-cannulated screws (Experiment 2).

Reversal of the Histology of Bone After Parathyroidectomy in Patients With Hyperparathyroidism*--Deepak V. Chavda, MD; James T. Frock, MD; Cecile M. Zielinski, MD; Donald J. Walla, MD; Michael H. McGuire, MD

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Hyperparathyroidism is commonly seen in patients with end-stage renal disease and less commonly in the primary form. The skeletal manifestations of hyperparathyroidism are the same in both forms and are well described in the literature. We treated a patient from each category. Multiple bony lesions and pathologic fractures were observed. The clinical presentations and radiologic and histologic findings confirmed the diagnosis of hyperparathyroidism and osteitis fibrosa cystica in both patients. Subtotal excisions of the parathyroid glands were done in both patients. Appropriate treatment of the bony lesions and pathologic fractures resulted in healing. Histologic evaluation of the bony lesions indicated an osteoblastic or healing response. The reversal of the histologic pattern in just 5 days and 16 days after parathyroidectomy was noted. In treating such patients, physicians should consider parathyroidectomy as an aid in the overall management of patients.

Chronic Osteomyelitis of the Tibia: Treatment With Hyperbaric Oxygen and Autogenous Microsurgical--Michael L. Maynor, MD; Richard E. Moon, MD; Enrico M. Camporesi, MD; Tom A. Fawcett, MD; Philip J. Fracica, MD; Helen C. Norvell, RN; L. Scott Levin, MD

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To establish the success rate of combined therapy for tibial osteomyelitis, we reviewed all cases of this infection treated with surgery, antibiotics, and hyperbaric oxygen (HBO) between 1974 and 1991 at Duke University Medical Center. The median delay from diagnosis of osteomyelitis to initiation of HBO was 12.5 months (range, 1 month to 684 months). Of 34 patients in whom follow- up data were complete, 27 (79%) were male and 7 (21%) female, with a mean age of 37.9 years (range, 20 years to 77 years). Patients received an average of 8.3 surgical procedures (range, 2 to 19) and 35 HBO treatments (range, 6 to 99). Twenty patients (59%) received free vascularized muscle flaps as part of therapy. Actuarial analysis was used to examine the effect of free vascularized flap procedures. Of 26 patients with 24 months of follow- up after treatment, 21 (81%) remained drainage free. At 60 months and 84 months after treatment, 12 of 15 (80%) and 5 of 8 (63%), respectively, were drainage free. After more than 84 months, patients who had received muscle flaps were more likely to be drainage free than patients who had received only debridement, and this difference approached statistical significance.

Management of Type III Acetabular Deficiencies in Revision Total Hip Arthroplasty Without Structural Bone Graft*--Charles J. Sutherland, MD

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Seventeen patients with loose total hip acetabular components and type III osteolytic acetabular defects were prospectively identified and reconstructed with either spherical acetabular components or eccentric acetabular components without use of structural bone graft. A computed tomography (CT) scan and a threedimensional (3-D) model were obtained in nine patients to determine whether a spherical component or eccentric component should be used. The clinical results were measured using the Harris Hip Score. Hip scores improved from 44 to 73 points for the entire group but were lower in the subgroup with eccentric components. Also, two of the eccentric cups developed loosening. The hip center was better restored in the eccentric implant group. The cost of the prosthesis was higher in the eccentric implant group due to the expenses of the CT scan and the 3-D model.

The Value of Serial Postoperative Radiographs of Total Knee Arthroplasties--H. Clayton Thomason III, MD; Robert R. Slater, Jr., MD; Ghassan S. Tooma, MD; Mihail R. Rosu, PhD; Scott S. Kelley, MD

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In a prospective study of 35 cemented press fit condylar knees, we studied the prevalence of radiolucent lines 1 mm wide or wider using two methods of detection: conventional (plain) and fluoroscopically-guided radiographs. All films were evaluated in accordance with the Knee Society Total Knee Arthroplasty Roentgenographic Evaluation and Scoring System. A total of 12 radiolucencies were detected in nine knees (26% of all knees) using conventional radiographs versus 25 radiolucencies in 13 knees (37% of all knees) using fluoroscopically- guided radiographs. This was a statistically significant difference and suggests that the true prevalence of periprosthetic radiolucencies will be underestimated if conventional radiographs are used to evaluate the bone-prosthesis interfaces and questions the value of routine postoperative plain film radiographs to evaluate the results of knee arthroplasty.

Bilateral Bowleg Deformity in a Child With an Adolescent Bone Age*--George W. Simons, MD; Ron Lamdan, MD

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Bowleg deformity in childhood has been studied extensively over the past century.1-25 There are now at least seven recognized causes based on radiographic appearance; five of these have readily recognizable underlying pathology. These are benign bone tumors (eg, fibrocortical dysplasia,2 Ollier’s disease), rickets, osteogenesis imperfecta, osteomyelitis, and trauma. The distinction between the other two, physiologic genu varum (PGV), a self-limited condition, and pathologic tibia varum (Blount’s disease) is not always clear initially. However, as the disease progresses, distinct radiographic characteristics develop that help distinguish Blount’s disease from PGV.1,7,11,14-16,19

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